Fournier’s Gangrene
A 57-year-old male with a history of T2DM, COPD, and HFrEF presented with severe scrotal pain and swelling. Physical examination revealed extensive edema, erythema, and necrotic eschar of the scrotum. Laboratory findings showed signs of infection and dehydration. Immediate interventions including fluid resuscitation and vasopressors were deemed necessary. Management involves surgical debridement and IV antibiotics targeting polymicrobial infections commonly seen in Fournier's gangrene. Appropriate initial empiric antibiotic regimens and the importance of clindamycin in inhibiting toxin formation are discussed.
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Presentation Transcript
Fourniers Gangrene Scott Cordts, MD
Case Presentation 57 yo WM with PMH of T2DM, COPD and HFrEF (20%) secondary to ASCVD presented with a 3-day history of severe scrotal pain and swelling. VS: T 37.2 C, P 88, R 18, BP 80/40 BMI 24.1 He appears ill. Mucous membranes are dry.
Case Presentation Extensive edema, erythema, and warmth to the entire scrotum that extends into the perineum and right buttocks. Necrotic black eschar of the lower scrotum with crepitance. Minimal discharge but foul smell present.
Case Presentation WBC 15.6 (10% Bands) Glucose 145, Na 127, BUN 119, Cr 4.2 Serum lactate 1.6 (Normal)
Questions for Discussion Is this patient stable or unstable and why? He is unstable. He appears ill, dehydrated and is hypotensive. What should be your first intervention to address his blood pressure? Isotonic fluid bolus If his blood pressure does not improve despite adequate fluid resuscitation, what further intervention should you take? Addition of vasopressors
Questions for Discussion Does he require any diagnostic imaging prior to treatment? No although CT or MRI can delineate the extent of infection, they should not delay definitive treatment The definitive treatment for this condition is? Surgical debridement + IV antibiotics Is this infection typically caused by a single microorganism or is it polymicrobial? Fournier s gangrene is typically a polymicrobial infection. (Goldstein, et al., 2007)
Questions for Discussion What would be an appropriate initial empiric antibiotic regimen? Carbapenem or beta-lactam-beta lactamase inhibitor PLUS agent with activity against MRSA (vancomycin or daptomycin) PLUS clindamycin Why is clindamycin always added, even in the presence of other agents with gram positive and anaerobic coverage? It also inhibits exotoxin formation. Can this infection occur in women? Yes, although it is more common in men, women can present with the infection typically involving the labia. (Stevens, et al., 2014)
Practice Pearls Fournier s gangrene is a necrotizing infection of the perineum and is a surgical emergency requiring prompt debridement when diagnosed. The infection is polymicrobial and should be treated with broad-spectrum antibiotics until culture results are available and the patient is improving clinically.
References Goldstein EJC, Anaya DA, Dellinger EP. Necrotizing Soft-Tissue Infection: Diagnosis and Management. Clinical Infectious Diseases. 2007;44(5):705-710. Stevens DL, Bisno AL, Chambers HF, et al. Executive Summary: Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2014;59(2):147-159.
